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VIII
25 How to Create a Recurrence
Introduction
For many years, repair of inguinal hernias was primarily
based on Bassini-like repairs, aiming to re-enforce or re-
establish a weak or absent posterior wall of the inguinal
canal by using the anatomical structures bordering the
defect, with many of the differences in the various open
surgical techniques described being rather subtle.
Previous studies have shown recurrence rates of non-
mesh repairs in the range of 20–30% with highest recur-
rence rates after Bassini repair [1–4], and in most large
series, the rate of operation for a recurrence approaches
16–18%, confirming the high recurrence rates of past non-
mesh inguinal hernia repairs.
This study presents the results after Bassini repair,
based on data from the Danish Hernia Database.
Material and Methods
The analysis was based on 74,131 elective inguinal her-
niorraphies recorded in the Danish Hernia Database in
the period 1 Jan. 1998 to 30 June 2005 (
⊡
Table 25.1
). The
setup and organization of the Danish Hernia Database
is described elsewhere [5, 6]. In brief, the database re-
cords basic information, including type of repair, on all
(> 98%) inguinal and femoral herniorraphies performed
in Denmark, based on schemes filled out by the operat-
ing surgeon at time of operation. The database uses rate
of operated recurrences as a proxy for recurrence and
patient-specific observation time is calculated by the use
of unique social security numbers. Cumulative re-opera-
25.1 Bassini
M. B-N, H. K
⊡
Table 25.1. Number of herniorraphies, age, operative
findings and rate of operation for recurrence. Danish
Hernia Database 1 Jan. 1998 to 30 June 2005
Bassini Lichtenstein
No. of hernior-
raphies
1383 48,400
Median age 56 years 58 years
Direct/indirect
hernias
60/40% 56/44%
Primary/recurrent
hernias
88/12% 89/11%
256 VIII Primary Inguinal Hernia
25
tion rates are shown as Kaplan-Meier plots and compared
by use of log rank test. Hazard ratios for risk factors are
calculated using multivariate Cox proportional-hazards
regression. P < 0.05 is considered significant.
Results
Of the 74,131 elective inguinal herniorraphies re-
corded in the Danish Hernia Database, 1383 (1.8%)
were Bassini repairs. The use of Bassini repairs declined,
from 4% in 1998, to < 0.5% in 2005, concomitant to an
increase in the use of Lichtenstein repairs from 34 to
78% (
⊡
Fig. 25.1
). Only small differences were found,
comparing age, ratios direct/indirect hernias and pri-
mary/recurrent repairs for Lichtenstein and Bassini
repairs.
Kaplan-Meier estimates of re-operation rates
show a significantly higher re-operation rate af-
ter Bassini repair, compared to Lichtenstein repair
(
⊡
Fig. 25.2
) while analysis of re-operation rates after
Bassini repair, shows a re-operation rate after repair
of direct inguinal hernia being twice that of indi-
rect hernias, and recurrent repairs having almost
three times the re-operation rates of primary hernias
(
⊡
Table 25. 2).
0
year
20
40
60
80
1998
1999
percentage
2000 2001 2002 2003 2004 2005
Lichtenstein
laparoscopic
other open mesh
other conv. open
Bassini
observation time [months]
2
6
rate of r-eoperations [%]
0
0
4
10
10
20 30 40 50 80
8
60 70 90
p<0.001
Bassini vs. Lichtenstein
hazard ratio 2.5 (95% CI 2.0 –3.0)
⊡
Fig. 25.1. Changes in use of operative
techniques, Danish Hernia Database Jan.
1988 to June2005. n = 74,131 elective in-
guinal herniorraphies
⊡
Fig. 25.2. Kaplan-Meier estimates of
re-operation rates, Bassini (n= 1383) and
Lichtenstein (n = 48,000) repair of elective
inguinal hernia, Danish Hernia Database 1
Jan. 1998 to 30 June 2005. p < 0.05 com-
paring Bassini and Lichtenstein repair (log
rank test)
257
VIII
How to Create a Recurrence
Discussion
These data from the Danish Hernia Database confirm a
high rate of reoperation after Bassini repair (10% after
7 1/2 years).
Although mesh implantation in itself has been sus-
pected to be a factor in chronic postherniorraphy pain,
previous studies do not confirm this relation [7] and
no evidence exists showing an advantage of the Bassini
repair in other outcome parameters.
As a consequence of the unacceptably high risk of
recurrence after Bassini (and other open non-mesh
repairs) and the absence of data supporting the use
of Bassini repair, the use of Bassini repair should be
abandoned.
Conclusion and Consequences
To create a recurrence after a Bassini-type inguinal
herniorraphy is easy: you just do it and leave the rest
to time and gravity. The use of Bassini repair should
be abandoned.
References
1. Tran VK, Putz T, Rohde H (1992) A randomized controlled trial
for inguinal hernia repair to compare the Shouldice and the
Bassini-Kirschner operation. Int Surg 77: 235–237
2. Paul A, Troidl H, Williams JI, Rixen D, Langen R (1994) Ran-
domized trial of modified Bassini versus Shouldice inguinal
hernia repair. The Cologne Hernia Study Group. Br J Surg 81:
1531–1534
3. Hay JM, Boudet MJ, Fingerhut A, Poucher J, Hennet H, Habib
E, Veyrieres M, Flamant Y (1995) Shouldice inguinal hernia
repair in the male adult: the gold standard? A multicenter
controlled trial in 1578 patients. Ann Surg 222: 719–727
4. Strand L (1998) Randomized trial of three types of repair
used in 324 consecutive operations of hernia. A study of the
frequency of recurrence. Ugeskr Laeger 160: 1010–1013
5. Bay-Nielsen M, Kehlet H, Steering committee of the Danish
hernia data base (1999) Establishment of a national Danish
hernia data base: preliminary report. Hernia 3: 81–83
6. Bay-Nielsen M, Kehlet H, Strand L, Malmstrom J, Andersen
FH, Wara P, Juul P, Callesen T (2001) Quality assessment of
26,304 herniorrhaphies in Denmark: a prospective nation-
wide study. Lancet 358: 1124–1128
7. Bay-Nielsen M, Nilsson E, Nordin P, Kehlet H (2004) Chronic
pain after open mesh vs. sutured repair of indirect inguinal
hernia in young males. Br J Surg 91: 1372–1376
Discussion
Campanelli: I don’t agree with your conclusion. If you
follow the original steps of Bassini repair, it’s a perfect
repair. You can do it ambulant under local anesthesia and
you can achieve the same results as with a mesh repair.
So what are your specific steps of Bassini repair?
Bay-Nielsen: It’s not my repair. I just described how sur-
geons do the Bassini in Denmark.
Kingsnorth:
I think the problem is that you don’t have
control over the surgeons. But you have more control over
surgeons doing Lichtenstein because they are able to ap-
ply the principle of the repair better and achieve results
close to Lichtenstein, while general surgeons don’t appear
to be able to apply the basic principles of the Bassini to
get his results.
Bay-Nielsen: It gives us the ability to say: you do a Bassini
repair, these are your results, and you should do some-
thing else.
Read: I was surprised that the incidence of indirect hernia
was less than the incidence of direct hernia in the popu-
lation who are operated upon. This is against the main
experience with this type of hernia.
Bay-Nielsen: I cannot comment on that.
⊡
Table 25.2. Risk factors, comparing elective inguinal
Bassini (n = 1383) and Lichtenstein repairs (n = 48,400)
Risk factor Hazard ratio, comparing
Bassini and Lichtenstein
(95% CI)
Age (> 65, ≤ 65) 1.2 (0.8–1.8)
Direct vs. indirect 2.1 (1.4–3.1)
Recurrence vs. primary 2.7 (1.7–4.2)
258 VIII Primary Inguinal Hernia
25
Introduction
To the serious and dedicated surgeon, it would be unthink-
able to expect a career without being competent in the
performance of a pure tissue repair for inguinal hernias.
It would be unrealistic if not careless. To accomplish this
competence will not be easy, for it will take valiant and
diligent effort not to be overwhelmed or intimidated by
the manufacturers and salesmen of surgical prosthetics,
instruments and implements. Although it is a necessary
evil of marketing strategies to sell indiscriminately if not
wantonly, the onus is on the surgeon to be steadfast and
show perspicacity, for he is the guardian of his patient’s
most prized possession: his well-being.
This is not a plea for blind conservatism but a call for
an informed liberal choice. A pure tissue repair is always a
proper operation when the pathology consists of an indirect
inguinal hernia. This is nearly always the case for children,
young adults, females as well as many adults who present
with a pure indirect inguinal hernia. That is, unless an indi-
rect sac has a neck wide enough to involve the posterior
inguinal wall. The use of mesh is properly indicated for direct
inguinal hernias, femoral hernias whether or not associated
with an indirect inguinal hernia and recurrent hernias. Per-
haps the most important reason to be adept with a pure
tissue repair is that it imparts knowledge that will enable
you to manage any situation in the groin, particularly during
emergencies when incarceration, strangulation or bacterial
contamination of the operative site may proscribe the use of
prostheses. Important, too, is that you are the one to decide
what is best for your particular need. No one else has made
that decision for you at a sales strategy powwow!
The number of pure tissue repairs derived from Bassi-
ni’s technique is now well over 80 and counting [1]. All
have quietly disappeared but for the Shouldice repair.
The Shouldice repair itself has been recognized by many,
quietly, to be really a Bassini with no difference to justify
a new appellation. The fact, too, is that no particular tech-
nique was ever described by Shouldice himself. The pres-
ent discussion and recommendations will apply therefore
to the Shouldice as well as the Bassini repairs. I always
find it ironic to read that the Shouldice repair yields bet-
ter results than the Bassini repair. The good results of the
Shouldice Hospital are, in no small measure, the result of
an expertise acquired from doing thousands of procedures
to the exclusion of all other surgical operations, by a team
of dedicated surgeons. Who among us does not recall that
the Bassini repair was taught as a “modified Bassini” and
therefore, by not resecting the cremasters and not open-
ing the posterior inguinal wall but imbricating it instead,
one did a corruption of that repair which evidently leads
to poorer results! Shouldice respects the very steps intro-
duced by Bassini, adding a second running suture in the
reconstruction for good measure.
Another digression, about the McVay repair this time,
begs to be made since the dissection is entirely a Bassini-
Shouldice dissection without the resection of the cremas-
ter. It is still performed by a few surgeons, though their
number is dwindling. McVay’s contribution was made at a
time when mesh was not in common use and, when used,
was fraught with and evoked unwarranted fears. The McVay
contribution was one of exquisite understanding of the
anatomy of the groin. As a hernia repair, it was beset by a
moderate incidence of recurrence, suffered from too much
tension and pain and was associated with a constant, if low,
incidence of femoral vein complications. Most notable is
the fact that a recurrence from a true McVay repair is always
the most difficult dissection one can expect while doing
open surgery on a recurrent inguinal hernia.
How does one then, “create” a recurrence while per-
forming a Shouldice repair? The answer must be provided
under five headings:
▬ Magnitude of the problem.
▬ Corruption of the established technique.
▬
Shouldice against odds. Attempting to perform a
Shouldice repair in a class of hernia where a pure tis-
sue repair is known to yield poor results.
▬
Inadequate knowledge of the anatomy and pathology
of the groin.
▬ Specifics.
Magnitude of the Problem
The incidence of recurrence following inguinal hernia
repairs varies between 8 and 33%, and depends on the
operative technique [2]. In the hands of the Shouldice
Hospital surgeons who rely on the Shouldice repair only,
that is to say when mesh is not used, that incidence varies
between 1 and 20% [3]. Looking at pre-mesh days (up to
1983), the results can be assessed from
⊡
Table 25. 3
.
With reference to recurrence rates following pri-
mary inguinal hernia repairs, the Shouldice Hospital
claims an incidence of less than 1%. However, I have
25.2 Shouldice
R. B
259
VIII
How to Create a Recurrence
never seen a study emanating from the Shouldice group
analyzing the extent of the follow-up that would be ac-
ceptable to a statistician. My own attempt at follow-
ing 400 patients from their records alone, from 1986 to
1996, yielded a dismal follow-up of 10% only [4]. The
literature reports incidences of recurrences as high as
12.5% at 4 years [5]. On a yearly basis, 13–15% of all
patients presenting at or, referred to the Shouldice Hos-
pital are already recurrences and persisting with the use
of the Shouldice repair may well be a way of “creating”
a hernia! At least by their own admission.
Corruption of Established Techniques
A chronic bane in surgery is the blind improvisation of
a particular step in a well-established operation. This
variation is often perpetrated without the benefit of a
defining study to confirm the premise or pretence of
that variation. This is seen when the Bassini or Shoul-
dice repairs are carried out without the resection of the
cremaster or without the division of the posterior wall
of the inguinal canal or when reconstruction is carried
out by “imbrication” of the transversalis fascia or when
the external oblique aponeurosis is approximated under
the cord, leaving the latter in the subcutaneous position.
These shortcuts usually lead to shortcomings.
Shouldice Against Odds
The Shouldice Hospital, which remains a bastion of
pure tissue repairs, has finally conceded that, in fact,
there are situations when “mesh is indicated”! Like a
man who has long been used to suspenders, wearing a
waist belt only feels somewhat unsafe still! Their own
statistics do reveal at last that mesh must be the order
of the day when dealing with recurrences. Often, unfor-
tunately, recurrences are due to missed and overlooked
hernias during a previous attempt at herniorrhaphy. If
such a missed hernia is an indirect inguinal sac, a Shoul-
dice repair may well be safely attempted. A Shouldice
repair should not be attempted in the presence of a di-
rect inguinal hernia. The reason will be examined under
the next heading. The Shouldice repair should not be
modified to include the ligament of Cooper. This has
been proposed by a surgeon, resulting in a McVay type
of repair in order to correct a co-existent femoral her-
nia [6]. In such a modification, the resulting operation
would be closer to a McVay than to a Shouldice. Though
this modification may perhaps handle a small femoral
hernia, a double-blind study was never carried out and
cases needing mesh were excluded from the series since
they were too large to handle by a suture repair! In other
words patient selection took place, negating the study
and casting much doubt on the results [6, 7].
Inadequate Awareness of Inguinal
Anatomy and Pathology
It is often said that the anatomy of the groin is the most
difficult with which one has to contend. That is probably
the case and this is reflected by the unaltered incidence
of hernia recurrences in the past three decades despite
the addition of prosthetic sheets, prosthetic gadgets and
laparoscopic mastery [8]. Adequate textbooks abound
which discuss the anatomy of the groin; however, many
can be confusing, unless one is to dedicate the necessary
time to study them. The anatomy lab and the operating
room are ideal places to identify, confirm and crystallize
the acquired knowledge.
Hernia pathology used to imply progressive changes
in anatomy secondary to the mechanical strains and
stresses of daily life, work and ageing. Today, there is a
resurgence of interest in the biological and metabolic as-
pect of hernia disease, particularly, more recently, at the
cellular, nuclear, chemical and molecular level. Scientific
activity is centred on the nature and changes taking place
within the collagen tissue as a result of inherited factors
or external deleterious stimuli e.g. smoking [9].
Specifics
How then, specifically, does one “create a recurrence”
during a Shouldice-Bassini repair? The answer is, of
necessity, speculative, since no-one has ever gone about
⊡
Table 25.3. Shouldice Hospital: own re-recurrences
from 1057 operations [3]
1x
recurrent inguinal hernia
18/775 12.3%
2x 15/212 17%
3x 16/49 12%
4x 11/14 17%
5x 11/5 20%
6x 10/2 10%??
260 VIII Primary Inguinal Hernia
25
to knowingly create such hernias. Logic and a smatter-
ing of detective work will help.
1. The skin incision is often suggested to be, in most
textbooks, 2 to 3 cm above a line joining the anterior
superior iliac spine to the pubic spine. Personal and
practical experience dictates that the incision must
be on and along that very line from the anterior su-
perior iliac spine to the very level of the pubic spine
to provide an optimal exposure of the relevant site
of surgery. This location displays easily the medial
portion of the floor of the canal where recurrences
occur most often. The undersurface of the liga-
ment of Poupart becomes clearly visible at the level
of the femoral triangle, where a femoral hernia can
be routinely searched for and excluded. An incision
so situated minimizes tension by the retractors, for
these are often the very source of marked discomfort
during surgery under local anaesthesia.
2. Resection of the cremasterics permits the accurate
identification, without fail, of an indirect sac at the
medial aspect of the cord at the internal ring. In
the series of 1057 recurrences seen and reported by
Obney and Chan [3], 37% of the recurrences turned
out to be indirect inguinal hernias (missed hernias?)!
45% were direct inguinal hernias, 8% were femoral
hernias (most likely overlooked also) and in 10%,
two or more hernias were discovered.
3. Division of the posterior wall of the inguinal canal
allows the examination of the preperitoneal space,
the identification of femoral pathology and rare her-
nias. But above all, it affords the identification of
good tissue layers which will allow for a solid repair.
The posterior inguinal wall will not be made up of
a weak, thin and translucent transversus abdominis
fascia and its posterior layer, the true transversalis
fascia which is part of the endopelvic fascia.
4. Division of the cribriformis fascia is a small surgical
step, requires little time and pays off handsomely in
terms of discovering a femoral hernia which would
otherwise have become a missed hernia and there-
fore a recurrence.
5. Nowadays, the division of the posterior wall of the
inguinal canal must come under scrutiny. Is it a nec-
essary step in all patients undergoing the Bassini or
Shouldice repairs? Many of the Shouldice surgeons
with whom I shared surgical opinions over many
years varied in their approach. Oftentimes, when
the wall and the tissues were good, the wall was not
divided. Why divide a good structure and run the
risk of a recurrence which, if it takes place, will do so
at the very medial end of this wall just lateral to the
pubic spine? Some surgeons take the middle of the
road by dividing the posterior inguinal wall halfway
only. I very rarely divide the posterior inguinal wall
in women because they seldom have direct hernias
or in patients who have an indirect inguinal her-
nia with a good posterior wall and in children. In
women the occurrence of a direct hernia is low, 1
out of 12 primary inguinal hernias compared to 1
out of 2 in men [10]. If one considers that women
make up 5% of the hernia population, their chance
of having a direct inguinal hernia is 0.4% of all in-
guinal hernias!
6. When direct inguinal hernias are present, they
must be considered to be secondary to metabolic,
genetic and chemical factors which lead to tissue
degeneration and therefore hernia formation. In
these patients, the use of prostheses is justified and
recommended [9]. We have seen above that in the
hands of the Shouldice surgeons, the incidence of
re-recurrence can be between 2.3 and 20% when
they repair recurrences without mesh. The patients
at their hospital present with a recurrence number
12–16% of the total number of patients [11]. Yet,
mesh was used in only 0.86% of recurrent indirect
inguinal hernias and in 5.78% of direct inguinal her-
nias. Somehow, logic is being ignored and a reason-
able conclusion would be that the Shouldice Hospital
is instrumental in “creating hernias” while doing a
Shouldice repair [12]!
7. The relaxing incision is a most trusted manoeuvre
in relieving tension in pure tissue repair. Introduced
by Wolfler in 1892, it was re-introduced by Berger
in 1902 and Halsted in 1903 [13]. It has since been
adapted in 12 variations [13]. Koontz confirmed
experimentally that“ not only does an incision over
fascia over good muscle not weaken the structure,
but the fascial covering is rapidly regenerated [14].
I have used a relaxing incision in over 2200 cases
without a single cause for regret. I have often seen,
while performing a generous relaxing incision as far
as the level of the internal ring that an interstitial or
low Spigelian hernia becomes evident which will
invariably require a mesh repair. In this case, the
hernia was not “created”, it was discovered!
Conclusion
Alexis Carrel, the Nobel laureate in medicine in 1912,
remarked that “the very fame of a specialist renders
him dangerous”. I thought a long time about this. Did
he mean that man becomes welded to his thoughts and
techniques and promotes them to the reckless exclusion
261
VIII
How to Create a Recurrence
of all logic and deference to worthy and newer chal-
lenges? This may well be. It is a form of slavery from
which man must detach himself. For his sake, for the
sake of science, but above all for the sake of man.
References
1. Bendavid R. New techniques in hernia repair. World J Surg
1989; 13: 522–531
2. Weber A, Garteiz D, Valencia S. Epidemiology of inguinal
hernia: A useful aid for adequate surgical decisions. In: Ben-
david R, Abrahamson J, Arregui ME, Bernhard J, Phillips EH
(eds) Abdominal wall hernias. Springer, Berlin Heidelberg
New York, 2001
3. Obney N, Chan CK. Repair of multiple time recurrent Inguinal
hernias with reference to common causes of recurrence.
Contemp Surg 1984; 25: 25–32
4. Bendavid R. Introduction to pure tissue repairs. In: Bendavid
R, Abrahamson J, Arregui ME, Bernhard J, Phillips EH (eds)
Abdominal wall hernias. Springer, Berlin Heidelberg New
York, 2001, p 353
5. Champault G, Barrat C, Catheline JM, Rizk N. Groin hernias- 4
year result of two randomized prospective studies. Hernia
1998; 2: 19–23
6. Welsh DRJ, Alexander MAJ. The Shouldice repair. Surg Clin
N Am 1993; 73: 451–469
7. Degani CT. Femoral hernia repair. A five year prospective
study. American Hernia Society Meeting; February 9–12/2005
in San Diego, Ca. Abstract #19–1
8. Schumpelick V. Herniosis: Recent understanding. San Diego
conference of American Hernia Society, Feb 9–12, 2005:Ab-
stract Book, # 46-I, page 114
9. Bendavid R. The unified theory of hernia formation. Hernia
2004; 8: 171–176
10. Glassow F. Inguinal hernia in the female. Surgery, gynecology
and obstetrics. 1963; 116: 701–704
11. Bendavid R. The Shouldice repair. In: Nyhus LM, Condon RE
(eds) Hernia IV. Lippincott, Philadelphia, 1995, p 223
12. Shouldice EB. The Shouldice repair for groin hernias. Surg
Clin N Am 2003; 83: 1181
13. Bendavid R. Relaxing incisions. In: Bendavid R, Abraham-
son J, Arregui ME, Bernhard J, Phillips EH (eds) Abdominal
wall hernias. Springer, Berlin Heidelberg New York, 2001,
pp:343–346
14. Koontz AR. Hernia. Appleton-Century-Crofts; New York, 1963,
pp 52–53
Discussion
Kingsnorth: Does the suture material you use contribute
to recurrence? You still use stainless steal wire?
Bendavid:
I have switched to polypropylene suture mate-
rial. The danger of stainless steel is that you have sharp
ends and you very often get pricked.
Miserez:
I have two questions. Do you advocate doing
anything with the posterior wall in the young adult and
in women, or do you just leave like it is? Do you still use
four layers for a Shouldice repair?
Bendavid:
In women, direct hernias are never a problem,
they normally don’t occur. In indirect hernias we just
narrow the internal ring and we rarely see a recurrence.
Concerning the second question: we still do the four-layer
repair. In about 15 to 20% we add a relaxing incision to
make it as tension-free as possible.
Flament:
Five years ago during a meeting organized by
Prof. Lange, 500 surgeons were asked what to do with a
2 cm lateral hernia and 95% answered that they would
do a Shouldice repair. This is just a statement.
Kingsnorth: This is an important statement.
Kurzer:
When we talk about the Shouldice or the Bassini
repair, we talk about procedures which have a high ef-
ficacy, but only in the hand of experts. But a hernia repair
is only effective if it can be spread easily to the rest of the
surgical community. The advantage of the onlay mesh
repair is that it can be spread to the general surgeon and
still gives good results. The suture repairs have efficacy
but only the onlay mesh repair has effectiveness as an
operation in the surgical community.
Bendavid: I agree with you. The Lichtenstein repair can
be done even by worse surgeons with good results. There
is no doubt that the Shouldice is not an easy operation.
Chan:
There are two things that I should like to say.
First of all, direct hernia recurrence is not only from a
Shouldice repair. If you use big bites and put too much
tension on your suture, you will have a medial recur-
rence with any type of repair. Furthermore, you have to
be aware not to miss a small indirect hernia, which still
accounts for several recurrences. The third is that doing
the Shouldice repair you may open the femoral canal by
putting too much tension on your suture line. If you want
to see the anatomy and the exact technique, come to the
Shouldice Hospital and follow us for a week or two. Mesh
is seldom necessary, we use mesh in only about 1% of
the cases.
Kehlet: I want to come back to the results of the two na-
tionwide registers we have, Sweden and Denmark. Here
we see that Shouldice is a catastrophe. Do you really still
recommend the Shouldice? When you do the Shouldice
it might provide good results because you are experts.
But it has been proven in several studies that it does not
function in the general community.
Bendavid:
The registers just reflect what you put in them.
But you don’t have any control over the surgeons.
Deysine:
You cannot learn a Bassini or a Shouldice from
a book or a drawing. The only way for a general surgeon
to learn the Shouldice is to go to Toronto and to watch
you operating. In the region where I live nobody can do
a Shouldice besides Berliner.
262 VIII Primary Inguinal Hernia
25
Bendavid:
I agree, the Shouldice is not an easy opera-
tion and you have to move and learn it from an ex-
pert.
Schumpelick:
I would like to comment on Dr. Kehlet. I
agree with you. Very often where Shouldice is written
about, it is no Shouldice. A lot of surgeons do the opera-
tion with no knowledge of anatomy. We re-operated more
than 200 of these cases. I think the name Shouldice is not
the operation of Shouldice.
Muschaweck:
Dr. Kehlet, I think the Shouldice is not a
catastrophe. You have to do the Shouldice correctly and
then you will have excellent results.
Bendavid: The advantage of having learned the Shouldice
technique is that afterwards you are able to manage any
problems in the groin and use any other technique of
repair, including all the mesh techniques.
Kehlet:
We are here as hernia experts and we have to give
advice for hernia surgeons around the world. I do not say
that Shouldice is a disaster in expert hands, but when
every surgeon is doing it, it is probably not a Shouldice at
all and they should not do it or even try to do it.
Kingsnorth:
A lot of surgeons want to have a fall-back
operation when they do not want to proceed with a Lich-
tenstein repair. In those countries where surgeons believe
that they should not put a mesh in a group of patients,
they need a tissue repair. There is no doubt that the Shoul-
dice is the best tissue repair if it is applied correctly. In
countries where surgeons believe that the Lichtenstein can
be applied universally, the Shouldice repair is irrelevant.
But in countries where a tissue repair is still supported by
a group of surgeons, it is their duty to apply the correct
Shouldice, which unfortunately is quite difficult.
Introduction
Lichtenstein tension-free hernioplasty began in 1984.
In the late 1980s, analyzing data from our own hernia
registry, published in 1987, we identified the following
flaws [1].
1. The mesh did not extend beyond the pubic tubercle
to overlap the pubic bone.
2. The mesh was too small (only 5×10 cm) to provide
enough mesh tissue contact beyond the inguinal
floor.
3. The mesh was kept flat (
⊡
Fig. 25.3, broken line), and,
therefore, was subject to tension when the patient
stood up from the supine position of the operation.
4. The upper edge of the mesh was fixed using a continu-
ous suture, which potentially left the iliohypogastric
nerve at risk.
5. Passing the genital nerve and external spermatic vessel
through a gap along the suture line of the mesh with
inguinal ligament exposed the nerve to potential risk
of entrapment.
In 1989, to correct the above problems, a set of principles
(outlined below) was established by our group, employed
with satisfactory results, and reported in 1993 [2].
Key Principles of the Lichtenstein Tension-
Free Repair
1. Use a large sheet of mesh that will extend approxi-
mately 2 cm medial to the pubic tubercle, 4–5 cm
above the Hesselbach triangle, and 5–6 cm lateral
to the internal ring (
⊡
Fig. 25.4
). We suggest using
a 7×15 cm sheet of mesh for easy handling, then
trimming 3–4 cm from its lateral side.
25.3 Lichtenstein
P. A
⊡
Fig. 25.3. Cross-section of the tension-free repair demon-
strating an inverted direct hernia sac and the dome-shaped
laxity of the mesh versus a completely flat mesh (dotted
line)
263
VIII
How to Create a Recurrence
2. Cross the tails of the mesh behind the spermatic cord
to avoid recurrence lateral to the internal ring (see
⊡
Fig. 25.4
). Suturing the tails together in a paral-
lel position, without crossing, is a known cause of
recurrence lateral to the internal ring area.
3. Secure the mesh with two interrupted sutures on
the upper edge and one continuous suture with no
more than three to four passes on the lower edge of
the mesh to prevent folding and movement of the
mesh in the mobile area of the groin (see
⊡
Fig. 25.4
).
Fixation of the mesh prevents movement, folding,
and wadding of the mesh ( meshoma) (
⊡
Fig. 25.5),
which can cause chronic pain and recurrence of the
hernia [3].
4. Keep the mesh with a slightly relaxed, tented up,
or buckled configuration (see
⊡
Figs. 25.3, 25.4
)
to counteract the forward protrusion of the trans-
versalis fascia when the patient stands up from the
intra-operative supine position, and to compensate
for contraction of the mesh.
5.
Visualize and protect the ilioinguinal, iliohypogas-
tric, and genital nerves throughout the operation
(
⊡
Fig. 25.6
). The iliohypogastric nerve can be iden-
tified easily, while the external oblique aponeurosis
is being separated from the internal oblique layer to
make room for the mesh. Because of a natural ana-
tomic cleavage, separation of these two layers from
each other is easy, fast, and bloodless. The most vul-
nerable part of the iliohypogastric nerve is its intra-
muscular segment (
⊡
Fig. 25.6
, dotted line), which
runs along the lower edge of the internal oblique
muscle (the so-called conjoint tendon). Passing a
suture through the internal oblique muscle to ap-
proximate this layer to the inguinal ligament (dur-
ing tissue approximation repairs) to a plug (during
mesh plug repair) or to the upper edge of the mesh
(during Lichtenstein repair) is liable to injure the
intramuscular portion of the iliohypogastric nerve
with the needle or entrap the nerve with the suture
[4]. The genital nerve is protected by not removing
⊡
Fig. 25.4. Extension of mesh beyond the boundary of the
inguinal floor (dotted line) 1 1.5–2.0 cm medial to the pubic
tubercle, 2 4.0–5.0 cm above the inguinal floor, 3 5.0–6.0 cm
lateral to the internal ring
⊡
Fig. 25.5. CT scan image of a meshoma (above). The explanted
meshoma (below)
⊡
Fig. 25.6. Neuro-anatomy of the inguinal canal
⊡
Fig. 25.7. Paravasal nerves within the lamina propria of vas
deferens
264 VIII Primary Inguinal Hernia
25
the cremasteric muscle and keeping the easily vis-
ible blue external spermatic vein with the spermatic
cord while it is being lifted from the inguinal floor
[4]. Removing the cremasteric muscles exposes
the genital nerve, paravasal nerves (
⊡
Fig. 25.7),
and the vas deferens to the mesh, which may lead
to chronic inguinodynia, orchalgia, and/or pos-
sible infertility [5] respectively. The ilioinguinal
nerve can easily be located over the spermatic
cord. Manipulating and lifting the nerve from its
natural bed will increase the risk of perineural
fibrosis and chronic postherniorrhaphy inguino-
dynia [4].
Causes of Recurrence after Lichtenstein
Tension-Free Hernia Repair
Causes of recurrence can be grouped in two categories:
(1) material-related causes and (2) technique-related
causes.
Material-Related Causes
▬
Mesh shrinkage: According to our clinical and
laboratory studies reported in 1995, after implan-
tation in vivo, mesh shrinks by approximately 20%.
Shrinkage of mesh can lead to recurrence of hernia.
Recurrence, however, can be prevented by extending
the mesh well beyond the boundary of the inguinal
floor.
▬
Mesh deformity related to the textile engineering
of the mesh: Certain structural designs of meshes
leads to narrowing of the mesh in the perpendicular
direction of stretching the mesh (
⊡
Fig. 25.8). As a
result the narrowed centre of the mesh can pull away
from its attachment to the host tissue and lead to
recurrence.
Technique-Related Causes
These include:
1. Failure to extend the mesh for approximately 1.5–
2.0 cm medial to the pubic tubercle, 4–5 cm above
the inguinal floor, and 5–6 cm lateral to the internal
ring.
2. Failure to keep the mesh slightly relaxed or buckled
up to account for forward protrusion of abdominal
wall in response to increased intra-abdominal pres-
sure when the patient stands up from the surgical
supine position and begins routine daily activi-
ties.
3. Inadequate mesh fixation that can lead to wrinkling
of the mesh and recurrence of hernia.
References
1. Amid PK. Lichtenstein tension-free hernioplasty: Its incep-
tion, evolution, and principles. Hernia 2004; 8: 1–7
2. Amid PK, Shulman AG, Lichtenstein IL. A critical scrutiny of
the open tension-free hernioplasty. Am J Surg 1993; 165:
369–371
⊡
Fig. 25.8. Central narrowing of mesh in
vertical direction with the mesh stretched
in horizontal direction
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